Focused Abdominal

Sonography in Trauma
FAST
 Trauma Ultrasonography
Intro
Applications
Anatomy
Comparison
Exam: Technical
Considerations
RUQ
LUQ
Subxiphoid/Subcostal
Pelvis
Ultrasonagraphic evaluation
of pathologic states
FAST: Intro and Applications

FAST exam: Focused Abdominal Sonography

in Trauma
Peritoneal
Pericardial
Pleural
Indications
Acute blunt or penetrating trauma
Trauma in pregnancy
Pediatric trauma
Subacute trauma
Goal: to identify fluid in a location where it
does not normally belong
FAST: Anatomy

7 dependent sites
1. Right Supramesocolic
(Morisons pouch)
2. Left Supramesocolic
(Splenorenal rescess)
3. Right Pericolic gutter
4. Right Inframesocolic
5. Left Inframesocolic
6. Left Pericolic gutter
7. Pelvic cul-de-sac
 The most
Intraperitoneal Fluid Flow important
preoperative
objective in the
management of
the patient with
trauma is to
ascertain
whether or not
laparotomy is
needed, and not
the diagnosis of
a specific organ
injury
Technique

Low frequency probe

2.5 5.0 MHz
Tissue penetration
 4 vazna anatomska segmenta

(RUQ) desno gore

Perihepatic Pericardial
polovina pozitivnih nalaza
krv

subxifoid

(LUQ) lijevo gore

Pelvic Perisplenic
Suprapubicno - Morison

ostalo

www.Trauma.org
Sub-xiphoid
Hepato-renal Recess

Trendelenburg position
Anterior axillary line
Right Lung Base

Left Lung Base

Move probe cephalad

Spleno-renal Recess
Pelvis

Pelvic Free Fluid

FAST: Technical Considerations

Probe placement?
1. RUQ: Morrisons Pouch
2. LUQ: Splenorenal
3. Pelvis: Pelvic cul-de-sac
1. Transverse
2. Longitudinal
4. Subxiphoid/Subcostal:
Pericardium

Remember: Probe almost

ALWAYS facing either
patients right or patients
head
 E-FAST
Focused
Assessment with
Sonograghy for
Trauma Indications
Cardiac
RUQ
Blunt thoraco-
LUQ abdominal trauma
Pelvis Unexplained
Extended hypotension
Lung bases for pleural
fluid Trauma in pregnancy
Anterior lung apices for
pneumothorax
Key Questions

Is there FREE FLUID

present?
In the pericardial
space
In the peritoneal
cavity
In the pleural space

Is there a
PNEUMOTHORAX?
 Advantages Disadvantages

Rapid Difficult to distinguish

Reproducible Type of fluid
Non-invasive Solid organ injury
Portable Cannot evaluate
No radiation retroperitoneum
or contrast Difficult in the obese patient

In the hemodynamically unstable pt, they

could be responding to fluids if surgeons
were wanting to evaluate the patient a bit
more, in pt with neg FAST, CT scan or
repeat US can be entertained. (further
delineate injuries)
The FAST Exam in the Literature

Study n sensitivity(%) specificity(%) npv(%)

Ballard et al, 1999 102 28 99 85

Boulanger et al, 1996 400 81 97 96

Chiu et al, 1997 772 71 100 98

Coley et al, 2000 107 38 97 78

Hoffmann et al, 1992 291 89 97 93

Ingeman et al, 1996 97 75 96 92

Kern et al, 1997 518 73 98 98

Liu et al, 1993 55 92 95 84

McElveen et al, 1997 82 88 98 96

McKenney et al, 1996 996 88 99 98

Rozycki et al, 1993 470 79 96 95

Rozycki et al, 1995 365 90 100 98

Rozycki et al, 1998 1227 78 100 99

Shackford et al, 1999 234 69 98 92

Thomas et al, 1997 300 81 99 98

Tso et al, 1992 163 69 99 96

Wherret et al, 1996 69 85 90 93

Yeo et al, 1999 38 67 97 93

Total 6324 75 98 94

Courtesy of Mark Brown

Pitfalls in the FAST Exam

Failure to scan Morison's pouch in the vertical plane,

ideally from the midclavicular line. A horizontal
scanning plane in the patient's midaxillary line may
miss free fluid.
Excessive focus on the required views.
Failure to scan systematically and slowly through the
four areas in real time.
Failure to identify clotted blood.
Failure to consider ascites as a cause for free fluid.
The only thing worse than a slow FAST is an
inaccurate FAST.

http://www.cpr.org.tw/ettc/fast_exam.htm
The Radiologists Prospective

Blood is a dynamic substance and is NOT

anechoic initially!
When a clot begins to retract after a
certain time it leaves behind anechoic
plasma
Very similar to free fluid
Hematomas contain a variable amount of
internal echoes during the first month, and
then gradually become anechoic1
1
Wicks JD. Silver TM. Bree RL. Gray scale features of hematomas: an ultrasonic spectrum. American
Journal of Roentgenology. 131(6):977-80, 1978 Dec
Results of B-Mode Scans

All fluids imaged sonographically were

clearly detectable as echo-free regions
The results indicate that internal echoes
within the fluid are not dependent on the
nature or concentration of a solute, nor is
their presence a result of high viscosity
Pathologic fluid collectionsmay
show little acoustic enhancement
Filly RA. Sommer FG. Minton MJ. Characterization of biological fluids by
ultrasound and computed tomography. Radiology. 134(1):167-71, 1980 Jan.
But

Blood clots in water showed a decline in

echogenicity throughout the experiment.
The A-mode imaging was effectively able
to follow blood clot echogenicity changes
under these controlled conditions

Peter DJ. Flanagan LD. Cranley JJ. Analysis of blood clot echogenicity. Journal of
Clinical Ultrasound. 14(2):111-6, 1986 Feb
Radiology Journals

Abdomens were scanned for free fluid and for

parenchymal heterogeneity in visceral organs;
scans that depicted these were considered
positive
In the presence of medical ascites (e.g. cirrhosis
or other cause of nontraumatic intraperitoneal
fluid), free fluid was considered positive because
hemoperitoneum could not be excluded

Farahmand, N, Sirlin, CB, Brown, MA, et al. Hypotensive patients with blunt abdominal
trauma: performance of screening US. Radiology 2005; 235:436
Kimura A, Otsuka T: Emergency center ultrasonography in the evaluation of hemoperitoneum: A
prospective study. J Trauma 31:20, 1991
Kimura A, Otsuka T: Emergency center ultrasonography in the evaluation of hemoperitoneum: A
prospective study. J Trauma 31:20, 1991
Not so FAST

The FAST examination was considered positive if it demonstrated evidence

of free intra-abdominal fluid
FAST examination results were compared with CT scan findings, noting the
discordance
FAST examination had a sensitivity of 42%, a specificity of 98%, a positive
predictive value of 67%, a negative predictive value of 93%, and an
accuracy of 92%
Six patients with false-negative FAST examinations required laparotomy for
intra-abdominal injuries
Of the 313 true-negative FAST examinations, 19 patients were noted to
have intra-abdominal injuries without hemoperitoneum and 11 patients were
noted to have retroperitoneal injuries

Use of FAST examination as a screening tool for blunt abdominal trauma in

the hemodynamically stable trauma patient results in underdiagnosis of
intra-abdominal injury. Hemodynamically stable patients with suspected BAI
should undergo routine CT scanning

Miller, MT, et al. Not so FAST. J Trauma 2003; 54:52

 The Fallacy of the Secondary Examination

Hypothesis: A repeat abdominal ultrasound may

allow for the duration necessary to accumulate
the prerequisite amount of blood for detection by
the majority of surgical ultrasound operators
Criteria: Secondary ultrasounds (SUS)
performed between 30 until 24 hours after
admission
Technique: All US and SUS exams were
considered positive if any intraperitoneal fluid
was identified
Blackbourne et al. Secondary ultrasound examination increases the sensitivity of the FAST exam in
blunt trauma. Journal of Trauma-Injury Infection & Critical Care. 57(5):934-8, 2004 Nov
Conclusions

Most Trauma and ER literature incorrectly

identifies intraperitoneal blood as anechoic
One hypothesis for this is that the time between
trauma and ultrasound is sufficient enough for the clot
to begin to separate
Secondary exam is more sensitive because the
separation of plasma and clot not more bleeding
Because most exams do correctly identify old
clot, the FAST exam is still a useful tool for
diagnosing bleeding if a sufficient time has
passed since injury
FAST
Advantages
Can be performed in 5
minutes at the bedside
Non-invasive
Repeat exams
Sensitivity and
specificity for free fluid
equal to DPL and CT
Disadvantages
Operator dependent
May not identify
specific injury
Poor for hollow viscus
or retroperitoneal
injury
Obesity, subcutaneous
air may interfere with
exam
FAST Principles
Pelvis and Supra-
mesocolic areas
Detects free
communicate
intraperitoneal fluid
Phrenicolic ligament
Blood/fluid pools in prevents flow
dependent areas Liver/spleen injury
Pelvis Represents 2/3 of cases
Most dependent of blunt abdominal
Hepatorenal fossa trauma
Most dependent area
in supramesocolic
region
FAST limitations

US relatively insensitive for detecting

traumatic abdominal organ injury
Fluid may pool at variable rates
Minimum volume for US detection
Multiple views at multiple sites
Serial exams: repeat exam if there is a
change in clinical picture
Operator dependent
FAST

Perform during
Resuscitation
Physical exam
Stabilization
Equipment

Curved array
Various footprints
Small footprint for
thorax
Large for abdomen
Variable frequencies
5.0 MHz: thin, child
3.5 MHz: versatile
2.0 MHz: cardiac, large
pts
Time to Complete Scan

Each view: 30-60 seconds

Number of views dependent on clinical
question and findings on initial views
Total exam time usually < 3-5 minutes
1988 Armenian earthquake
400 trauma US scans in 72 hrs
FAST

Increased sensitivity
with increased number
of views
Will identify pleural
effusions
Reliably detects as little
as 50-100cc in the
thorax
Sensitivity >96%,
specificity 99-100%
Clinical experience with FAST
Intraperitoneal fluid
Sensitivity 82-98%, specificity 88-100%
Morisons pouch alone 36-82% sensitivity
Increased sensitivity with
Increasing number of views
Trendelenberg
Serial examinations
Can detect as little as 250cc of free fluid
Solid organ disruption
40% sensitivity for all organs
33-94% for splenic injury
Hollow viscus injury
Sensitivity 57%
Retroperitoneal injury
Sensitivity for identification of hemorrhage <60%
RUQ

Probe at right thoraco-

abdominal junction
Liver : large acoustic
window
Probe marker cephalad
Rib interference?
Rotate 30
counterclockwise
Scan Plane

Same image if
probe positioned
Anterior
Mid axillary
Posterior
RUQ

Image on screen:
Liver cephalad
Kidney inferiorly
Morisons Pouch*: *
*
space between
*
Glissons capsule
and Gerotas fascia *
Normal RUQ

Image kidney
Longitudinally
Transversely
Two toned structure
Cortex/medulla
Renal sinus
Appearance of blood

Fresh blood
Anechoic (black)

Coagulating blood
First hypoechoic
Later hyperechoic
 Normal
Morisons
Pouch

Free fluid in
Morisons
Pouch
Positive FAST Exam

Normal - Morisson Positive FAST -

Morrison
 Positive FAST in a Patient with Ascites

Intraperitoneal fluid may be

Blood
Preexisting ascites
Urine
Perihepatic fluid collection Intestinal contents

Liver parenchyma
www.frca.co.uk/ images/A-031.jpg
Volume Assessment by US
Caveat to Branney study:
Artificial condition: infused fluid
Fluid in Morisons after pelvis overflow
Tiling et al :
200 -250ml detected by US
Collection >0.5cm suggests over 500ml
Transvaginal/rectal
15ml of free intraperitoneal fluid
Detection of Fluid by Ultrasound

Affected by Value of sensitivity

positioning of Ultrasound:
Location of bleed Detects clinically
injuries
Rate of bleeding
Non-detection of fluid
Operator Experience May indicate self-
limited bleeding
All Fluid is not Blood

Ascites
Ruptured Ovarian Cyst
Lavage fluid
Urine from ruptured bladder
Mimics of Fluid in RUQ

Perinephric fat
May be hypoechoic like blood
Usually evenly layered along kidney
If in doubt, compare to left kidney
Abdominal inflammation
Widened extra-renal space
Echogenicity of kidney becomes more like the
liver parenchyma
Pitfalls

RUQ
Not attempting multiple probe placements
Not placing the probe cephalad enough to use the
acoustic window of the liver
Scanning too soon before enough blood has
accumulated
Not repeating the scan
 Probe placed
Perpendicular
FAST: RUQ exam Mid-coronal plane
Just superior to the iliac crest
Probe facing
Toward patients head
Evaluating
Hepatorenal interface
Possibility of fluid in Morisons
pouch - Right Supramesocolic
space
Technical Problems
Bowel gas
Rib artifact
FAST: RUQ exam

Where exactly is Morrisons Pouch?

FAST: RUQ exam

Normal Anatomy
In the supine patient,
Morisons
Pouch the hepatorenal space
is the most dependent
area
Also is the least
obstructed for fluid
flow
Morisons Pouch
Potential space
between the liver and
the right kidney in the
hepatorenal recess
 Abnormal
FAST: RUQ Anatomy
exam Pathologic Fluid
mild and moderate

L = liver
K = Kidney
FF = free fluid
RS = rib shadow
D = diaphragm
FF1 = free fluid
FF
L
K

RS
D
LUQ
Probe at left posterior axillary
line
Near ribs 9 and 10
Angle probe obliquely (avoid
ribs)

Scan plan - More difficult

Acoustic window (spleen) is
smaller than liver
Mild inspiration will optimize image
Bowel interference is common
LUQ Scan

*
spleen *

* kidney
*

*Splenorenal fossa a potential space

 Normal
Spleno-renal
view

Free fluid
around spleen
 Probe placed
Perpendicular
FAST: LUQ exam Mid - coronal plane
Just superior to the iliac crest
Probe facing
Towards patients head
Evaluating
Spleno-renal interface
Possibility of fluid in
splenorenal recess
Technical Problems
Bowel gas, splenic flexure gas
Rib artifact
FAST: LUQ exam

Where exactly is Splenorenal Recess?

FAST: LUQ exam

Splenorenal
Recess
Normal Anatomy
More difficult to evaluate
than RUQ
Left kidney more superior
than right
Do not have liver as acoustic
window
Splenorenal Recess
Potential space between kidney
and spleen
FAST: LUQ exam

Pathologic
Fluid

K = kidney
S = spleen
RS = rib
shadow
FF = free fluid
 Probe placed
FAST: Subxiphoid exam
Patients epigastrium
Just below xiphoid process of the
sternum
entire probe aimed at patients left
shoulder
Probe facing
notch of probe placed toward
patients right side
Evaluating
Fluid in the pericardium
Wall dysfunction
R heart strain
Septal bowing
Technical Problems
Inability to get probe under xiphoid
FAST: Subxiphoid exam

Normal Anatomy
Liver at very top of
screen
Right ventricle on top
of screen
Right atrium and left
ventricle line up below
right ventricle
FAST: Subxiphoid exam

Normal Subcostal view

Most practical in trauma setting
- Away from airway and
IVS neck/chest procedures

RV = right ventricle
RA = right atrium
LV = left ventricle
LA = left atrium
IVS = interventricular
septum
FAST: Subxiphoid exam

Subcostal view
Large pericardial
Measure here! effusion

Where to you
measure amount of
blood or fluid? -
anteriorly between
the heart and liver
Penetrating Thoracic Injury
Clinical challenge
Where is the penetration?
What was the weapon?
What was the trajectory?
What organ(s) have been injured?
Improved outcomes in patients with normal or near-normal vital signs
Pericardial effusion
May develop suddenly or surreptitiously
May exist before clinical signs develo
Salvage rates better if detected before hypotension develops
Pericardial Effusion

Positive FAST demonstrating

Normal subcostal view of pericardium
pericardial effusion
Pericardial Fluid

fluid
Occult Penetrating Cardiac Trauma

Observation unreliable
Subxiphoid window
Invasive
100% sensitive, 92% specific
Negative exploration rates (as high as 80%)
Ultrasound reliable indicator of even small
pericardial effusion
Blunt Cardiac Trauma

Basic Assessments Advanced

Pericardial effusion Assessments
Assess for wall motion Assess thoracic aorta
abnormality may need TEE to
RV: see all of thoracic aorta
Hematoma
closest to anterior
chest wall Intimal flap
Most likely to be injured Abnormal contour
Valvular dysfunction or
septal rupture
Blunt cardiac trauma

Injuries difficult to assess by FAST

Valvular incompetence
Myocardial rupture
Intracardiac thrombosis
Ventricular aneurysm
Coronary Thrombosis
Intra-cardiac Thrombosis
Normal Lung
Lung Scanning for
Pneumothorax

Bat Sign
Comet tails
To Evaluate the Thorax

Move probe
cephalad
longitudinal
Image
Liver

Diaphragm

Pleural space
Hemothorax

liver

fluid diaphragm
Small Pleural Effusion

Large Pleural Effusion

FAST: Pelvis LA exam

Pelvis: Long Axis

Probe placed
longitudinally
2 cm superior to the
symphysis pubis
Midline of the
abdomen
aimed caudally into
the pelvis
Probe facing
Toward patients head
FAST: Pelvis LA exam

Evaluating
Free fluid in the anterior pelvis
Free fluid in the pelvic cul-de-sac (Pouch
of Douglas)
Technical Problems
Body habitus
Empty bladder (no landmarks)
Bladder trauma (no landmarks)
Pelvis: Long Axis
Normal Anatomy
Evaluating
Bladder
Uterus in female: usually superior to
bladder
Prostate in male: usually posterior to
bladder
Pelvic View

Probe should be
placed in the
suprapubic position
Either can be
transverse or
longitudinal
Helpful to image
before placement of a
Foley catheter
Pelvis (Long View)
Pelvis: Transverse
 Normal
Transverse
pelvic

Fluid in pelvis
Pelvic View Sagittal

clot bladder
Fluid in front of the
bladder
If bladder is empty
or Foley already
placed:
Trick of trade
IV bag on abdomen
Scan through bag
Blood in the Pelvis
FAST: TV Pelvis exam

Pelvis: Transverse
Probe placed
2 cm superior to the
symphysis pubis
Midline of the
abdomen
Probe facing
Toward patients right
Probe rotated 90
degrees
counterclockwise from
longitudinal
FAST: TV Pelvis exam

Evaluating
Free fluid in the anterior pelvis
Free fluid in the pelvic cul-de-sac (Pouch
of Douglas)
Technical Problems
Body habitus
Empty bladder (no landmarks)
Bladder trauma (no landmarks)
Pelvis: Transverse Axis
Normal Anatomy
Evaluating
Bladder
Well cirucumscribed
Contains fluid that appears anechoic
 Transverse
FAST: Pelvis exam - Pathology
scans with
free fluid in
pelvis
Female (top):
uterus
posterior to
bladder
Male
(bottom)
B = bladder
UT = uterus
FF = free
fluid
S = spine
Lacerations
FAST Algorithm

Normal Altered MS NO
Peritoneal US Confounding Injury
Hemodynamic
Y ES Irritation? NO Free fluid? NO Gross Hematuria
Status
HCT < 35%

NO Y ES Repeat U/S 30
Y ES
Y ES HCT at 4h
Observe 8h
Nonoperative
US: LAPAROTOMY Y ES
or
Free fluid? Y ES Abdominal CT
cirrhosis?

NO NO

DPL DPL
Branney, et. al.
J Trauma, 1997
Pitfalls

Scan all quadrants

Repeating scans
Inferior poles
Solid organ injuries
Fat
Retroperitoneum
The focused ultrasound for trauma; assessing
accuracy and techniques.
Margaux Snider MS4
FAST but out of
September 2007

Focus?
 What is the FAST?
Focused Assessment with Sonography for Trauma:
A bedside ultrasound exam done during trauma to evaluate for
intra-abdominal injury
May include many views (up to 12) but always
includes 4 main views:
1. Morrisons pouch RUQ, hepato-renal
recess
2. Pericardium subxiphoid, or long-axis
parasternal
3. LUQ, Spleno-renal recess
4. Pouch of Douglas suprapubic, between
rectum/uterus and bladder
FAST in the Emergency Room
Why do a FAST in the first place?

Represents a quick method to assess

for hemorrhage or abdominal injury
without interruption of resuscitation
(unlike CT)

Poses low to no risk of further injury to

already potentially unstable patient (1-
2% risk of bowel perforation with
diagnostic peritoneal lavage)
 The Literature
Study in 1970 by Goldberg, established ascites as anechoic
by ultrasound1.
Several studies following this began to characterize various
fluids from ascites to clotted blood and hematomas via
ultrasound2,4-8.
North American radiologists began studying US for use in
trauma starting in 198911,12
Emergency medicine physicians began prospective studies
using ultrasound to find free fluid in a trauma setting starting
in 199313.
 Literature Cont.
Jehle and subsequent studies13-20 cited Goldbergs
identification of ascites as anechoic and inaccurately used
blood and free fluid (including ascites) as interchangeable.
Ultrasound in trauma became known as the FAST acronym
in 1996, has been added to most level 1 trauma center
ATLS algorithms11,15 . However the training is still focused on
assessing solely for the presence of an anechoic stripe.
Several studies have attempted to address the variable
sensitivity of the FAST, examining such variables as use of
portable US20, retroperitoneal bleeding21-23, and size of
anechoic stripe29.
 The Images
A positive exam in the EM
literature is indicated by the
presence of an anechoic
stripe/region in one of the four
main views.
Anechoic stripe

A positive exam in the early

Radiology literature includes
assessing for heterogeneous
echogenicity and
parenchymal echo
abnormalities

Normal
 The Anechoic Stripe
An anechoic stripe on the FAST is thought to be the
definitive sign of a positive exam and represent
the presence of hemoperitoneum 14,15

What is actually anechoic on ultrasound?

1. Fluid such as ascites1,5 (not static blood)2,4,7
2. Active flow of blood as in blood vessels8,9
3. Older hematoma representing separation of
plasma and clot4,6,7
Blood on Ultrasound by Radiologists

Note that both serum and

water created the most
hypo-echoic regions,
whereas whole blood and
PRC appear relatively
heterogeneous to the
surrounding tissue; not
anechoic

Fig. above Ultrasound of phantom containing, from left to right: water

(H20), packed red cells (PRC), hemolysate (H), whole blood (WB),
serum (S) and water.
So whats the problem?
Blood from a newly formed hematoma, as would be
developing in a trauma patient, is not anechoic
initially. It appears as a collection of heterogeneous
internal echoes, similar to the echogenicity seen in
bowel loops and gradually becomes anechoic over
time 4,7,10

Although FAST examiners are frequently finding

anechoic regions on exam, it more likely represents
increased time of bleeding, and subsequent
separation of serum out from plasma. However,
many additional bleeds and early hematomas are
potentially being missed.
 Summary of Concerns

Lack of consistency: Multiple ED studies on the FAST have

shown a very wide range of sensitivity and specificity
values, from 28%-92%; and 95-100% respectively 11,12,15-21.
Limited Criteria: Almost all of these studies (those that did
specify their criteria) used solely the presence of an
anechoic stripe to delineate positivity.
 Faulty Assumptions:
1. These studies routinely cite a study assessing ascites as
evidence for the appearance of blood on ultrasound. They
routinely confuse free fluid, which could be from a variety
of causes, with hemoperitoneum
2. The study documenting increased sensitivity of the FAST
with serial exams postulated the newly found anechoic
stripe represented increased bleeding over time24
This study, however, failed to specify the time from the
actual trauma to the FAST exam, documenting only the
time from initial to follow up FAST exam and did not
consider changing blood character as a confound rather
than increasing amounts of blood.
 Hypotheses for proposed study

H1: Poor sensitivity and high false negative values may

represent failure to consider increased echogenicity of
surrounding organs and poorly visualized organ edges
(parenchymal echo abnormalities) as a positive exam.

H2: Presence of anechoic stripe on FAST with repeat exam

may represent increased time to exam from trauma, not
increased bleeding amount
Study Proposal

Prospective Study Participants:

Patients arriving at OHSU emergency department for whom
the trauma system has been activated.
Patients whom the trauma team deems appropriate to
receive a FAST exam, regardless of documented blunt
abdominal trauma.
Patients enrolled in study must have received per team
discretion both a FAST and abdominal CT or abdominal
surgery (to allow for verification of blood/fluid presence, or
organ injury)
Patients may be men or women 18-80 years old.
Reasonable approximation of time of trauma must be
attainable
Study Proposal

Methods Part 1
4 view frames (RUQ, pericardium, LUQ, suprapubic) of participant
FAST (ideally a video recording of entire FAST exam), saved,
identifying data removed.
Approximate time of trauma and time of FAST recorded at arrival
Exam is assessed by ED physician or resident certified for FAST
exam at time of trauma.

Classified as:
Positive based on presence of anechoic stripe or anechoic
fluid collection in any 1 or more of 4 views
Negative based on absence of anechoic region in all 4 views
Study Proposal
Methods Part 2
4 views which have been saved are then reinterpreted by
blinded sonographers or ultrasound trained radiologists
(unaware of final presence of fluid or ED read of FAST)
They are asked to classify the exam as follows:
Positive 1: presence of anechoic stripe/collection in any 1 or
more of 4 views
Positive 2: absence of anechoic stripe/collection but presence
of increased heterogeneous echogenicity or poorly
visualized organs (parenchymal echo abnormalities)
Negative: absence of either 1 or 2
Study Proposal

Confirmation of Findings
All subjects are documented as +/- free intra-
peritoneal fluid or blood based on CT or abdominal
surgery findings.
**Would be ideal to be able to quantify fluid but not sure how to do this
radiographically**
Intra-parenchymal injury observed on CT scan or during surgery without
peritoneal fluid/blood will be excluded as solid organ injury is not
specifically being assessed other than edge/echo abnormalities as it
contributes to identifying peritoneal fluid collections on ultrasound .
Any fluid visible on CT scan as read by radiologist, or >50ml fluid
visualized during surgery will be considered +.
Study Flow Chart
Initial FAST
obtained

Time from trauma

ED Physician Positive to FAST obtained
assessment
real time Negative

Sonographer Positive group 1

assessment
Positive group 2

Confirmation of Negative
fluid presence

CT Scan Abdominal Surgery Quantification of

fluid?
+/-
Outcomes
Accuracy, Sensitivity, Specificity, of ED readers and blinded
sonographers

Inter-rater reliability among ED and sonography assessors

NPV and PPV of FAST for both groups

Concordance of categorization:
Are the same exams being categorized correctly or
incorrectly among both ED physicians and sonographers
Outcomes cont.
Assess how sonographer positive 2s are recorded by ED
physicians are they always recorded as negative, or are
they deemed positive? Or indeterminate?

Assess time to FAST to determine:

1)whether longer time = more positive FAST exams among
both groups
2) whether longer time = significantly more anechoic positives

If possible, could examine the relationship of time to FAST

exam and quantity(?) of actual fluid observed, comparison
with presence/absence of anechoic stripe
Thank You
References
1. Goldberg BB, Goodman GA, Clearfield HR. Evaluation of Ascities by Ultrasound. Radiol. 96: 15-22;
1970.
2. Kaplan GN, Sanders RC, et al. B-Scan Ultrasound in the management of patients with occult
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